Heart valve repair apparatus and methods

ABSTRACT

Valve repair apparatus and methods for ensuring proper coaptation and operation of the leaflets of a heart valve. Main aspects of the disclosure relate to devices including a support member configured for attachment to the heart valve annulus, a post extending from the support member away from the plane of the annulus and a connector coupled with the post and configured for attachment to at least one of the leaflets. The various embodiments may include a replacement heart valve connected with the support member for facilitating full replacement as opposed to near repair of an existing native heart valve. Various other devices include support structure and one or more posts connected to opposite sides of the support structure and extending from one side of the valve annulus to another to modify the shape of the annulus.

This application is a divisional of application Ser. No. 10/695,380,filed Oct. 28, 2003 which is a divisional of application Ser. No.10/268,028 filed Oct. 9, 2002 (now U.S. Pat. No. 6,797,002) which is acontinuation of application Ser. No. 09/496,450 filed Feb. 2, 2000 (nowabandoned), the disclosures of which are fully incorporated herein byreference.

FIELD OF THE INVENTION

The present invention generally relates to heart valve repair andreplacement techniques and apparatus. More specifically, the inventionrelates to the repair of heart valves having various malformations anddysfunctions.

BACKGROUND OF THE INVENTION

The mitral valve depends on adequate apposition or alignment between theanterior and posterior leaflets along a relatively long surface areaunder high pressure conditions. Typically, the contact surface is about12 mm in a direction perpendicular to the anterior-posterior directionand this provides little margin of safety. The leaflet margins areattached to numerous fine chords suspended from attachment points alongthe inner surface of the left ventricle. Although these attachments areoften referred to as papillary muscles, there is often a very diffusearc-shaped attachment for each of the groups of chords to theendocardial surface. Unfortunately, this anchor point (i.e., the innerwall of the left ventricle) must move with each heartbeat and so thedistance between the attachment of the leaflet edges is constantlychanging. The chordal lengths may also change—typically increasing withage and degeneration and the chords frequently do not lengthen in asymmetrical fashion. This leads to variations in their lengths atall-important points of coaptation. Chords may also rupture. Inaddition, the mitral annulus changes diameter with each heartbeat suchthat it surface area changes by about 40% with each systole. As theheart enlarges, the annulus of the mitral valve can enlarge as well. Inshort, there are many variables affecting proper functioning of themitral valve. The anatomy, such as the leaflet length, the chordallength and the annular length/diameter can change. The attachment pointscan change as the ventricle changes shape. More importantly, all ofthese aspects can change simultaneously. For example, a patient may haveischemic mitral regurgitation which pulls the posterolateral valveattachments away from their natural coaptation points and leads to anopening in this area of the mitral valve. This can be further affectedif the chordal lengths are changed by even minor degrees of degenerativedisease.

Mitral valve pathology has changed remarkably since the origin of openheart surgery one generation ago. Initially, the most common pathologyor condition was rheumatic mitral valve disease. This producedthickened, impliable leaflets with grossly deformed chords, or chordaetendinae, often combined with fusion of the two leaflets. This valve wasnot suitable for any type of plastic procedure and, accordingly,numerous valve prostheses were developed to replace the entire valve,i.e., the annulus, leaflets and chords. Now, except in centers with highrates of immigration from third world countries, rheumatic mitral valvedisease is a relatively uncommon indication for surgery. Various formsof degeneration ranging from gross billowing of leaflets to relativelyminor chordal lengthening as well as ischemic mitral valve pathology aremost commonly encountered. Recently, it has become apparent thatcombinations of these two problems are relatively common. In both ofthese situations, the mitral valve leaflets are soft, pliable and can beretained over the long-term in various repair procedures. Unfortunately,despite the fact that the leaflet tissue is suitable for retention,mitral repair is performed for less than half of the cases where mitralregurgitation is the problem. In surgical centers where mitral repair isnot practiced, valves are often discarded and replaced.

One main problem is that mitral valve repair technology has not keptpace with the change in mitral valve pathology. Mitral valve repair ismore an art than a science and requires a constant interaction betweenvisual inspection and post operative results, as evidenced bytransesophageal echocardiography (TEE). Few surgeons or surgical centersare equipped for or capable of performing this type of work on a routinebasis. Many surgeons only perform mitral annuloplasty with rings thatreduce the diameter of the annulus. These rings may appear to be asolution for a variety of problems but are not ideal for many ischemicand degenerative disease conditions.

Despite many attempts, the homograft mitral valve replacement is not anoperation which can be performed reliably. It could have potentialadvantages in third world countries or in cases of infection. Failuresoccur because of the unreliability of attachment of the chords to theleft ventricle. It is not difficult to anchor the valve in the annulus.However, it is virtually impossible to ensure that the chords arecorrectly spaced inside the ventricle to produce a competent valve.Again, the inner surface of the ventricle is a moving surface and it isalmost impossible to guarantee that a chord extending from a leafletedge will be fixed in such a way that the anterior and posteriorleaflets are reliably aligned during valve operation.

Various other repair procedures are performed, but these are limited tothe removal of leaflet tissue which is poorly supported and to chordalshortening and replacement. Many valves simply remain unrepaired due tothe shortage of acceptable techniques and apparatus. The sophisticatedprocedures are acquired art forms that many surgeons either cannotmaster or do not have the time and opportunity to master.

Thirty years of valve surgery have indicated that the native leaflettissue is the most reliable valve material. Despite numerous attempts toproduce durable leaflet replacements, none have been found. The cost ofdemonstrating the value of a new material is extremely high. However,chordal replacement with polytetrofluorethylene is durable and highlysatisfactory. Therefore, this at least provides a proven, reliablematerial to suspend leaflet tissue.

It is also clear that annuloplasty rings are durable, well-tolerated anddo not require long-term anticoagulation. They fix the annulardimensions and reliably reduce one of the most important variables(i.e., the mitral annulus diameter) in mitral valve competence.

Regulatory issues in this field are the single most expensive factor.Next generation valve prosthesis designs are therefore most desirablybased on the numerous available annuloplasty devices.

To properly and consistently repair the mitral valve, these variablesmust be fixed—the annular diameter, the leaflet length, the chordallength and the attachment point of the chords. Fortunately, the leafletlength is relatively constant. The annulus diameter can be fixed by theannuloplasty ring. The chords can be replaced by polytetrofluorethylenesuture to fix their length. The missing variable is the attachment ofthe chords to the left ventricle. To date, this remains a troublesomevariable to the valve repair.

Ischemic mitral regurgitation occurs when there is ventriculardysfunction which causes the posterolateral attachments of the mitralvalve to be drawn away from the annulus in systole. This pulls the twoleaflet edges apart at their point of coaptation and produces anasymmetrical regurgitant jet or, in other words, blood flow in the wrongdirection through the valve. In its pure form, the leaflets, the chordsand the attachment points are all anatomically normal. Sometimes thereis a relative discrepancy between the distance the anterior leaflet isdrawn inward relative to the posterior leaflet so they are not justseparated from edge-to-edge but also there is a step deformity of thejunction point. The patient may also have some underlying mild degree ofdegenerative deformity which may initially cause a mild, butwell-tolerated degree of mitral regurgitation. However, theregurgitation often becomes severe after left ventricular ischemiaoccurs.

Some repair techniques apply tight annuloplasty rings which serve tobuckle the leaflets and draw them together. This often leaves a degreeof mitral regurgitation and mitral stenosis results. Annuloplasty can beaccompanied by a modification of the Alfieri edge-to-edge repair, morerecently referred to as the bowtie repair. With this technique, thesurgeon merely sews the anterior leaflet to the posterior leaflet at thepoint of maximal distraction. This produces a two orifice valve withmore stenosis.

Devices and methods are necessary that preserve the leaflet tissue butprovides for virtually guaranteed coaptation of the leaflets by fixingsome of the variables responsible for regurgitation. Other devices andmethods are necessary that do not simply reduce the diameter of a heartvalve annulus, but allow more specialized treatment tailored to patientneeds.

SUMMARY OF THE INVENTION

Degenerative disease generally involves a relatively normal leafletwhich is poorly supported by lengthened or ruptured chords. By attachingthe poorly supported leaflet to replacement or native chords connectedwith a post in the left ventricle, a guaranteed point of coaptation canbe produced. In this regard, one general form of the invention providesa device for supporting a heart valve in a patient with the heart valveincluding an annulus generally lying in a plane and a plurality ofleaflets connected therewith and adapted to open and close toselectively allow and prevent blood flow. The device comprises a supportmember configured for attachment to the heart valve and theabove-mentioned post extending from the support member and configured toextend away from the plane of the annulus. A connector is coupled withthe post and configured for attachment to at least one of the leaflets.The post can support the posterior leaflet (extending from the posteriorpart of the support member), the anterior leaflet (extending from theanterior part of the support member) or both leaflets. For example, thiswould require a relatively simple modification of the currentlyavailable annuloplasty rings or other support members, for example,which may be ring segments. The connector may be one or more flexibletensile members, such as replacement chords passing from the leaflet(s),through or along the post and up to the support member. These flexibletensile members may be precisely length adjusted to bring theunsupported leaflet edge to the precise depth. This could replace thecurrent posterior leaflet resection. It would also be a solution for theanterior leaflet repair which has produced only marginal results in mosthands. The invention is also applicable to replacement heart valvesformed of biologic or artificial materials. Various aspects of theinvention are applicable to the repair of native valves, while otheraspects apply to replacement valves of artificial biocompatiblematerial, animal valve tissue or human valve tissue.

A device constructed in accordance with the invention would preferablyfix the annular diameter, the chordal length and the point of chordalfixation in the ventricle. In this way, the invention provides a morereliable and permanent solution to the problems associated with thevalve repair. Furthermore, it would be easy to perform by most surgeons.A small incision could be made in the annular attachment of the poorlysupported anterior leaflet and the post passed through this incision.The support member would then be attached to the native annulus.Flexible tensile members, such as artificial or natural chords wouldthen be attached from the post to the unsupported edge of the leafletand adjusted by pulling them to length and fixing them. In the case ofreplacement chords, they are preferably fixed at the level of thesupport member. Devices could include posterior posts, anterior posts orboth. A variety of possibilities exist for modified structures,including multi-forked posts or surgeon-created posts. It would also bepreferable to provide chordal patterns to attach the posts to theleaflets and to develop a quick connect system for attachment of thechords to the leaflet edges. Adjustability of the system will beimportant in many cases for fine tuning.

Another form of the invention comprises a support member, which may bean annuloplasty ring or other support structure, and at least one post.A first chord gripping member is coupled with the post and configured togrip at least one of the chords and thereby fix the length of the chordbetween the first gripping member and the leaflets to support and alignthe leaflets for coaptation during operation of the valve. In the caseof mitral valve repair, the post extends into the left ventricle takingorigin from the posterolateral commisure. In a preferred embodiment, onegripping member traps the chords to the anterior leaflet in such a waythat their distance from the leaflet edge is precisely fixed. A secondpost and gripping member can do the same for the posterior leaflet. Thesurgeon would then confirm that the gripping members had captured thechords precisely so that the leaflets meet exactly in systole. If therewould be any doubt about this coaptation or should there be a fear oflate failure due to chordal rupture, the native chords could beaugmented or replaced by an array of replacement chords suspended fromthe posts and attaching to the leaflet edge. One may also postulateimproved left ventricular function from the device since the bulging ofthe posterior wall of the heart will be prevented by the tethering ofthe chords which are trapped in the device.

The various devices of this invention are formed of biocompatiblematerials including, but not limited to, exposed biocompatible metals,fabric covered metal or polymer, exposed polymer, or any otherbiocompatible artificial or biologic material. The various devices ofthis invention may also be incorporated into a full replacement heartvalve structure again formed from any biocompatible material for casesnecessitating full replacement of the valve. In these cases, thereplacement valve is fully supported in a position ensuring accuratecoaptation of the valve leaflets and less stressful interaction of thevalve leaflets with each other as well as with the valve commisures.

Another aspect of the invention provides a device for supporting a heartvalve in a patient comprising a support structure configured forattachment to the heart valve annulus and a post connected to oppositesides of the support structure and configured to extend from one side ofthe annulus to another side thereof. This modifies the shape of theannulus, for example, to correct for ischemic condition. The post may becontained substantially in the same plane as the support structure andvalve annulus or may extend substantially out of the plane containingthe support structure and valve annulus. If extending substantially inthe same plane, the post prevents outward bellowing of the valveleaflets, while if extending substantially out of the plane, the postsimply functions to connect and modify the shape of opposite sides ofthe annulus. The post may be length adjustable to allow variablemodification of the annulus and may include additional posts ofadjustable length or fixed length. As with other embodiments of theinvention, the support structure may comprise a ring-shaped member orone or more discrete support segments.

As another manner of correcting an ischemic condition, for example, aring-shaped support member is provided having an asymmetric-shape abouttwo perpendicular axes. Stated more generally, one side of thering-shaped support member may be of narrower width than an oppositeside of the ring-shaped support member. This may or may not be coupledwith a slight angling downward of one side of the ring-shaped supportmember with respect to the opposite side of the ring-shaped supportmember. These modifications help to close a gap created between thevalve leaflets due to conditions such as an ischemic condition.

In another aspect of the invention, a device is provided for adjustingthe distance between a papillary muscle and an annulus of a heart valve.This device comprises a support member configured to be affixed to theannulus of the heart valve and an elongate flexible tensile memberhaving first and second ends with the first end adapted to be fixed tothe papillary muscle. A connector is configured to connect with theelongate flexible member and with the support member in a mannerallowing adjustment in the length between the papillary muscle and thesupport member and fixation of the elongate flexible member at a desiredlength between the papillary muscle and the support member. Generally,this device is useful for setting the critical distance between thepapillary muscle and the valve annulus and may be used in preparationfor the various valve replacement and repair techniques and devicesdisclosed herein.

In another aspect of the invention, a device is provided for supportinga heart valve in a patient and generally comprising a support memberadapted to be affixed to the annulus and having at least one selectivelyadjustable portion allowing one section of the support member to bemoved with respect to another section thereof and locked in place inorder to maintain one or both of the annulus and the leaflets in adesired configuration. The support member may be ring-shaped, forexample, and may be selectively adjustable such that one section, lyingin a single plane, may be adjusted and angled away from a planecontaining another section of the ring-shaped support member.Alternatively, or in addition, the ring-shaped support member may beadjustable to allow one section to be narrowed in width with respect toanother section. This feature is also advantageous for correctingischemic conditions.

In one general method of supporting a heart valve in accordance with theinvention, a support structure is first connected to the heart valveannulus. A post is then fixed to the support structure, or the supportstructure may already have a post extending therefrom. The post is thenconnected to one of the valve leaflets to support the leaflets duringopening and closing thereof. In accordance with the various aspects ofthis invention, the post may be connected to the leaflet with a flexibletensile member, such as a natural or artificial chord, or may be moredirectly connected to the leaflet. One direct connection includesextending a wire coil from the post into two adjacent leaflets toconnect central portions of leaflets together. Other possibleconnections include the artificial or natural chord connectionsmentioned above.

Various objectives, features and advantages of the invention will becomemore readily apparent to those of ordinary skill in the art upon reviewof the following detailed description taken in conjunction with theaccompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective view of a first embodiment of the presentinvention being applied to a heart shown in partial cross section.

FIG. 2 is a perspective, partially sectioned view similar to FIG. 1 butenlarged and showing the device of this invention affixed to the mitralvalve.

FIG. 3 is a perspective, partially sectioned view of the device shown inFIGS. 1 and 2 with the mitral valve shown in cross section.

FIG. 4 is a partially fragmented, perspective view of the device shownin FIGS. 1-3.

FIG. 5 is a cross sectional view taken along line 5-5 of FIG. 4.

FIG. 6 is a fragmented perspective view of a device similar to thatshown in FIG. 4, but illustrating additional flexible tensile members orartificial chords.

FIG. 7 is a perspective view of a second embodiment of the inventionshown affixed to a mitral valve.

FIG. 7A is an alternative embodiment similar to the embodiment shown inFIG. 7.

FIGS. 8-14 illustrate various alternative mechanisms for grasping apatient's native or artificial chords and useable in conjunction withthe embodiment of FIGS. 7 and 7A.

FIG. 15 is another alternative embodiment of a support device shownaffixed to a heart valve.

FIG. 16 is another alternative embodiment of a support device for aheart valve.

FIG. 17 is a perspective view of another alternative embodiment of asupport device shown affixed to a heart valve.

FIG. 18 is a perspective view of another alternative support device fora heart valve.

FIGS. 19 and 20 are perspective views of alternative devices used toestablish a distance between a heart valve support ring and thepapillary muscles of a patient.

FIG. 21 is a fragmented view showing a heart valve with a malformationcaused by an ischemic heart muscle.

FIG. 22 is an elevational view of a support ring having an adjustabilityfeature in accordance with the invention.

FIG. 22A is a perspective view showing a portion of the ring of FIG. 22and an adjustability feature thereof.

FIG. 23 is an elevational view showing the ring of FIG. 22 applied tocorrect the malformation shown in FIG. 21.

FIG. 24 is a partially sectioned view showing an adjustable ring orheart valve support member connected to a heart valve and used inconjunction with a post of the present invention.

FIG. 25 is a perspective view of an alternative heart valve and heartvalve support.

FIG. 26 is a partially sectioned view of the device shown in FIG. 25with a catheter inserted through the heart valve.

FIG. 27 is a perspective, partially sectioned view of a device forestablishing the distance between the heart valve and the papillarymuscles of a patient.

FIG. 28 is a perspective view of an alternative heart valve supportdevice of the present invention.

FIG. 29 is a fragmented, partially sectioned view showing anadjustability feature between the post and the heart valve supportmember of this invention.

FIG. 30 is a perspective view of an alternative heart valve supportdevice shown affixed to a heart valve.

FIG. 31 is another alternative heart valve support device shown affixedto a heart valve.

FIG. 32 is a perspective view of another alternative heart valve supportdevice.

FIG. 33 is a perspective, partially sectioned view of another heartvalve support device.

FIG. 33A is a perspective, partially sectioned view of anotheralternative heart valve support device.

DETAILED DESCRIPTION OF THE ILLUSTRATIVE EMBODIMENTS

Referring first to FIG. 1, a device 10 for supporting a heart valve in apatient is shown. In the illustrated example, the left ventricle 12 of apatient's heart is shown in cross section with a mitral valve 14 forsupplying blood into the ventricle 12. Mitral valve 14 includes anannulus 16 generally lying in a plane and a plurality of native chordaetendonae or chords 18, 20 respectively connected with a pair of valveleaflets 22 a, 22 b at one end and papillary muscles 24, 26 at anopposite end. In a normally functioning heart, chords 18, 20 support theanterior valve leaflet 22 a and posterior valve leaflet 22 b betweenopen (diastolic) and closed (systolic) positions to selectively allowand prevent blood flow into and out of left ventricle 12. Blood entersleft ventricle 12 through mitral valve 14 and is expelled during thesubsequent contraction of the heart muscle through aortic valve 28. Itwill be appreciated that the present invention is applicable to heartvalves other than the mitral valve in various of its aspects to bedescribed below.

Device 10 more particularly includes a support member 30 configured forattachment to the heart valve annulus 16 and a post 32 extending fromsupport member 30 and configured to extend away from the plane ofannulus 16. A connector which, in this embodiment, is in the form of atleast one flexible tensile member, is coupled with post 32 andconfigured for attachment to at least one of the anterior and posteriorleaflets 22 a, 22 b. In this embodiment of the invention, post 32 is ahollow, J-shaped member having a longer section 32 a and a shortercurved section 32 b. Also, post 32 may be hollow as shown with flexibletensile members 34 extending through the post and exiting at shortersection 32 b. Flexible tensile members 34 may include suture needles foraffixing the tensile members to the edges of the anterior and posteriorvalve leaflets 22 a, 22 b as described below. Other connectors suitablefor directly or indirectly coupling post 32 or a post of differentconfiguration to the anterior and posterior valve leaflets 22 a, 22 bmay be utilized as well and some variations are described herein below.

As shown in FIG. 2, flexible tensile members 34 may completelysubstitute for one set of chordae tendonae 18 (FIG. 1) or, as analternative, one or more defective chords, such as a lengthened chord 18a (FIG. 1), may be replaced with an artificial chord or flexible tensilemember in accordance with the invention. As shown in FIG. 2, all of thenative chords 18 of the patient have been removed and device 10 has beenaffixed by suturing ring-shaped support 30 to valve annulus 16 usingstitches (not shown) and by affixing flexible tensile members orartificial chords 34 to anterior and posterior leaflets 22 a, 22 b. Asfurther shown in FIGS. 2 and 24, post 32 can extend along posteriorouter wall 12 a of the heart 12. Flexible tensile members 34 may beaffixed to mating edges of anterior and posterior valve leaflets 22 a,22 b by being stitched thereto as shown in FIG. 3 using suitable pads orsuture supports 40, 42. It will be appreciated that the remaining nativechords and other artificial chords have been omitted in FIG. 3 forclarity. A crimp member 44 is also shown in FIG. 3 for fixing flexibletensile members 34 at the desired length. That is, after chords 34 havebeen affixed to anterior and posterior valve leaflets 22 a, 22 b asshown in FIG. 3, the distance between the lower free margins or edges ofleaflets 22 a, 22 b and section 32 b of post 32 may be adjusted toensure effective coaptation or mating of the anterior and posteriorvalve leaflets 22 a, 22 b in their closed systolic configuration. Whenthis is achieved, crimp member 44 is crimped onto flexible tensilemembers 34 to retain flexible tensile members 34 at this distance andmaintain the effective coaptation. Ring-shaped support member 30 may becomprised of two integrated sections with one being a generallycurvilinear section 30 a for coupling adjacent to the posterior leaflet22 b and one being a straight section 30 b for coupling adjacent to theanterior leaflet 22 a as is the case with certain conventionalannuloplasty rings. FIGS. 4, 5 and 6 illustrate the hollow nature of thesupport post and the use of a number of flexible tensile members orartificial chords 34, depending on the patient's needs.

FIG. 7 illustrates a device 50 constructed in accordance with onealternative embodiment. In this embodiment, a valve annulus supportmember 52 is again shown as a ring-shaped member and a post 54 extendsaway from ring-shaped support member 52. Post 54 includes at least onechord gripping member 56 comprised of a pair of jaws 56 a, 56 b. In thisembodiment, a second chord gripping member 58 is shown also comprising apair of jaws 58 a, 58 b. Gripping member 56 is shown as grippinganterior native chords of the patient, while gripping member 58 is shownto grip posterior native chords of the patient. The purpose of device 10is to retain the use of the patient's native chords 18, but to morefully restore their function. In cases in which a patient's heart isischemic, there may be stretched or lengthened chords, such as chord 18a shown in FIG. 1. In this case, device 50 and, more particularly,gripping members 56, 58 may be used to capture chords 18 and place themunder suitable tension mimicking their natural, normal condition toprovide full support to valve leaflets 22 a, 22 b. FIG. 7A illustratesan alternative embodiment similar to FIG. 7, but having a annulussupport portion 52′ which is not ring-shaped, but nevertheless providessuitable support when attached to a valve annulus for supporting post54. It will be appreciated that, while this embodiment is especiallysuitable for use on a patient's native chords, similar chord grippingmembers may be used to capture artificial chords, such as sutures orgortex fibers, connected with the valve leaflet edges as previouslydescribed. Jaws 56 a, 56 b and 58 a, 58 b may be formed in any suitablemanner and may operate between open and closed positions also in anysuitable manner.

FIGS. 8-14 illustrate several different illustrative examples ofmechanisms for opening and closing the jaws of a gripping membersuitable for use in the embodiments of FIGS. 7 and 7A. FIG. 8illustrates a gripping member 70 comprised of jaws 72, 74 connected witha post 76 by respective shape memory rods 78, 80. When electric currentor heat is applied to rods 78, 80, jaws 72, 74 move together into aclamped or closed position.

In FIG. 9, gripping structure 90 is shown as comprising a pair of hingedjaws 92, 94 operable by a cam member 96 and an actuating wire 98contained within a post 100. When wire 98 is pulled and fixed, cammember 96 will cam jaws 92, 94 into closed or clamped positions on thepatient's native or artificial chords.

FIG. 10 illustrates a chord gripping member 110 comprised of first andsecond jaws 112, 114 pivotally connected together by a series of links116 and operable between open and closed positions by a wire 118contained within a post 120. When wire 118 is pulled in the direction ofarrow 122, and fixed, links 116 will move jaws 112, 114 to the closedposition.

FIG. 11 illustrates a chord gripping member 130 comprising a pair ofjaws 132, 134 hingedly connected together and contained within anactuating member 136 fixed within a post 138. When wire 140 is pulled inthe direction of arrow 142, jaws 132, 134 will be forced by actuatingmember 136 into their closed and clamped position. Wire 140 may then befixed in this position by any suitable means.

FIG. 12 illustrates another alternative gripping member 150 comprised offirst and second jaws 152, 154 hingedly connected together and pivotallysecured to a hollow post 156. A wire 158 is connected to the ends ofjaws 152, 154 and when pulled in the direction of arrow 160 jaws 152,154 will be actuated to their closed and clamped positions. Again, wire158 may be fixed in any suitable manner once gripping member 150 is inthe closed and clamped position.

FIG. 13 illustrates a gripping member 170 comprised of a movable jaw 172hingedly or flexibly connected with a post 174 and operable by a wire ormovable actuating member 176. An outer end of jaw 172 is retainedagainst a cam surface 178 of actuating member 176. When actuating member176 is pulled in the direction of arrow 180, jaw 172 will be forced toclose against member 176 and clamp the native or artificial chordstherebetween. Actuating member 176 may be fixed in any suitable mannerat this position.

FIG. 14 illustrates another alternative clamping member 190 comprised ofa movable jaw 192 hingedly or flexibly connected with a post 194 andoperable between open and closed positions by an actuating member orwire 196 which slides with respect to a stationary jaw 198. Movable jaw192 has one end retained against a cam surface 200. When actuatingmember or wire 196 is pulled in the direction of arrow 202, jaw 192 willbe forced to a closed and clamped position against jaw 198 by way of thecamming action of surface 200. Wire or actuating member 196 may be fixedat this position by any suitable means.

FIG. 15 illustrates another alternative valve support 210 constructed inaccordance with the invention. In this embodiment, valve support 210 maybe used as a support for a replacement heart valve 212, which may beformed from artificial or biological material. Valve support device 210more specifically comprises a pair of ring-shaped support members 214,216 with ring support member 214 being connected with the annulus ofvalve 212. Ring-shaped support member 216 is connected to support member214 in spaced relation by a series of posts 218, 220, 222, 224. Thisstructure supports a series of flexible tensile members, or artificialchords 226, 228, 230, 232 connected to the edges of valve leaflets 234,236 in a suitable manner, such as in the manner described with respectto the first embodiment.

FIG. 16 illustrates another alternative valve support device 250including a ring-shaped support member 252 configured to be connectedwith the annulus of a heart valve 254 and including a post 256 connectedtherewith. In this embodiment, post 256 includes a section 258 extendinginwardly toward the center of heart valve 254. This spaces post 256 awayfrom any potentially harmful contact with the inner wall of the heartmuscle. A series of flexible tensile members or artificial chords 260,262, 264, 266 extend outwardly from post 258 and include respectivegrippers 268, 270, 272, 274. Grippers 268, 270, 272, 274 may be used asalternatives to directly stitching these artificial chords to the valveleaflets. Instead, these grippers may simply be clamped onto the edgesof the valve leaflets to provide the same function as the attachmentshown and described with respect to FIG. 3, for example.

FIG. 17 illustrates another alternative valve support device 280comprised of a ring-shaped support member 282 fixed to a heart valve 284in any suitable manner and including a post 286. Post 286 is preferablyrigidly secured to ring-shaped support member 282 and extends throughthe center thereof so as to be configured to extend between the valveleaflets 288, 290. Post 286 is connected with or integrally includes achord supporting portion 292 at an opposite end and, as with the otherembodiments, flexible tensile members or artificial chords 294, 296 areconnected between support portion 292 and valve leaflets 288, 290.

FIG. 18 illustrates an alternative valve support device 300 comprised ofa ring-shaped support member 302 and preferably a pair of posts 304,306. Ring-shaped support member 302 is configured to be affixed to theannulus of a heart valve, as with various other embodiments of thisinvention, while posts 304, 306 are configured to prevent outwardbillowing of the heart valve leaflets. For this purpose, posts 304, 306may be slightly curved, as shown, in an outward direction with respectto the heart valve beneath.

FIG. 19 illustrates a device for setting the distance between theannulus of the mitral heart valve and the patient's papillary muscles.In particular, device 300 comprises a ring-shaped support member 302configured to be sutured or otherwise affixed to the annulus of theheart valve and a pair of flexible tensile members 304, 306, which maybe sutures, connected between the respective papillary muscles 308, 310of the patient and the ring-shaped support member 302. In thisembodiment, to facilitate connection with ring-shaped support member302, tensile members 304, 306 are slidably retained on crimp members312, 314 while the length or distance between papillary muscles 308, 310and ring-shaped support member 302 is set. Crimp members 312, 314 maythen be forced into respective holes 316, 318 and thereby crimped totensile members 304, 306 to simultaneously affix crimp members 312, 314to ring-shaped support member 302 and to the corresponding tensilemember 304, 306.

FIG. 20 illustrates an alternative device 300′ for setting the distancebetween a ring-shaped support member 302′ and the respective papillarymuscles 308, 310. In FIG. 20, reference numerals with prime (′) marksindicate subject matter similar to the corresponding reference numeralsin FIG. 19, while like numerals indicate like elements between thesefigures. Device 300′ includes a ring-shaped support member 302′configured to be connected to a heart valve annulus and including twoconnectors 320, 322 that affix tensile members 304, 306 to ring-shapedsupport members 302′ after ring-shaped support member 302′ has beenaffixed to a heart valve annulus, a surgeon stitches flexible tensilemembers 304, 306 to papillary muscles 308, 310 and after adjusting thedistance properly between papillary muscles 308, 310 and ring-shapedsupport member 302′, affixes tensile members 304, 306 to connectors 320,322. These connectors 320, 322 may include slots 320 a, 322 a whichallow flexible tensile members 304, 306 to become wedged and retainedtherein.

FIG. 21 illustrates a mitral heart valve 330 comprised of respectiveanterior and posterior leaflets 332, 334 that engage one another at anarea of coaptation 336 defining a selectively opened and closed portionof the valve 330. Valve 330 has a malformation, however, in the form ofa gap 338 that is typically the result of an ischemic condition, asdiscussed in the background, which pulls one portion or leaflet 334 ofthe mitral valve 330 away from the other leaflet 332.

FIGS. 22, 22A and 23 illustrate a valve support device 350 forcorrecting valve malformations such as that shown in FIG. 21. Thesedevices are especially useful for treating ischemic conditions in whichone side of the mitral valve pulls away from another side resulting inimperfect coaptation of the respective anterior and posterior valveleaflets 332, 334. Specifically, device 350 is in the form of aring-shaped support member 352 having a selectively adjustable andlockable portion 354. As shown best in FIG. 22, ring-shaped supportmember 352 may be reformed into the shape shown in phantom and retainedin that shape. Alternatively, device 350 may be formed with a permanentasymmetric shape about both axes x,y. As shown in FIG. 22, a first ormajor axis “x” extends along the maximum dimension of the support member352, while a second or minor axis “y” bisects the support member 352along the “x” axis. The major axis “x” generally divides an anteriorsection 352 a from a posterior section 352 b of support member 352. Theintersection of the “x” and “y” axes defines a valve flow axis 353extending normal to major axis “x” and minor axis “y.” As further shownin FIG. 22, a portion of posterior section 352 b is shown, in phantom,to be deformed inwardly generally toward flow axis 353 and anteriorsection 352 a. As shown in FIG. 23, the ability to squeeze portion 354of ring-shaped support member 352 together and retain portion 354 inthat position will bring the anterior and posterior valve leaflets 332,334 together to close gap 338. FIG. 22A illustrates one manner ofallowing selectively adjustable and lockable positioning of ring-shapedsupport member 352. In this regard, respective socket segments 354 a,354 b, 354 c receive balls 356 therebetween and further receive a wire358 which may be tensioned and locked in place with a set screw 360 byuse of a tool 362. When wire 358 and socketed segments 354 a-d and balls356 are loosened, adjustability of section 354 is possible. Once theadjustment in position is made, wire 358 is tensioned to bring the ballsand sockets together and then lock in place using tool 362. This retainsthe adjusted shape. As also shown in FIGS. 22 and 23, support member 352in this embodiment is a ring shaped member that is substantially “D”shaped when viewed in a direction parallel to the valve-flow axis 353(that is, in top view or bottom view). The anterior section 352 a isconfigured to form a substantially straight portion of the “D”-shapewith first and second ends at opposite ends of the straight portion, andthe posterior section 352 b is configured to form a substantiallyarcuate portion of the “D”-shape.

FIG. 24 illustrates another alternative device 370 for supporting amitral valve 372. Device 370 again comprises a valve support member 374adapted to be connected with the valve annulus 376, such as by suturingor other mechanical fastening means. A post 378 and flexible tensilemembers 380 are connected with support member 374 as described generallyabove in FIG. 2 to support anterior valve leaflet 382 and posteriorvalve leaflet 384. In this embodiment, one portion 374 a of valvesupport member 374 may be bent out of the plane containing anotherportion 374 b and retained in that position to fix the mitral valve 372in a desired position. In the embodiment shown in FIG. 24, a posteriorsegment 374 b overlying posterior leaflet 384 is bent downwards relativeto an anterior segment 374 a overlying anterior leaflet 382. Anysuitable manner of retaining the adjusted shape may be used, includingthe manner described with respect to FIG. 22A. Alternatively, device 370may be permanently formed with a nonplanar shape, such as the shapeshown in FIG. 24. It will be appreciated from a review of FIGS. 2, 22and 24 that the view of FIGS. 2 and 24, for example, is taken with theanterior portion 376 a of the valve annulus 376 and anterior segment 374a being on the left, and with the posterior portion 376 b of the valveannulus 376 and posterior segment 374 b being on the right. Therefore,the view of FIG. 24 is in a direction generally parallel to the majoraxis “x.” The mitral valve annulus 376 will assume the shape of theattached device 370. That is, the posterior portion 376 b of the annulus376 will be moved and fixed into a non-planar configuration, i.e., outof the natural position of the posterior valve annulus 376 b. In theembodiment shown in FIG. 24, the posterior portion 376 b of annulus 376is moved downward relative to the anterior portion 376 a of annulus 376.The modified shape shown in phantom in FIG. 22 may also be combined withthe modified shape shown in FIG. 24 for ring-shaped support member 374.

FIG. 25 illustrates another alternative valve support device 390incorporating a replacement heart valve 392 with the support structureincluding a post 394 and a plurality of flexible tensile members orsutures 396 extending from an end 394 a of post 394 and edges of threeleaflets 398, 400, 402 associated with valve 392. Flexible tensilemembers 396 are preferably distributed evenly along the edges ofleaflets 398, 400, 402 to support the leaflets during operation withproper coaptation or mating of the adjacent leaflet surfaces. Flexibletensile members 396 also reduce stress on commisures 393.

FIG. 26 illustrates a cross sectional view of a somewhat modified form390′ of support device 390 having a catheter inserted between the valveleaflets 398, 400, 402. In this embodiment, flexible tensile members 396prevent leaflets 398, 400, 402 from opening and closing against catheter410 with excessive force. This is in addition to stress reduction oncommisures 393. Such force may be harmful to valve 392. Catheter 410 maybe support within valve 392 by suitable struts or other support members412, 414.

FIG. 27 illustrates another alternative device in the form of aring-shaped valve support member 422 configured to be affixed to theannulus 424 of a heart valve. Device 420 is used to set the distancebetween the ring-shaped support member 422 and the papillary muscles425, 427 of the patient. A pair of posts 426, 428 extend generally in aradially inward direction from ring-shaped support member 422 and aredirected through the center of the valve between leaflets 429, 431 anddown along the patient's native chords 433, 435. Posts 426, 428 areaffixed to the patient's papillary muscles 425, 427 at the desiredlocation. This suitable fixes the location of chords 433, 435 and allowsthe surgeon to use any of the other valve support devices contemplatedby this invention to facilitate supporting the leaflets 429, 431 forproper coaptation. Once the appropriate valve support device or devicesare in place to properly support leaflets 429, 431, device 420, or atleast posts 426, 428, may be removed.

FIG. 28 illustrates another alternative valve support device 440comprised of a ring-shaped support member 442 configured for attachmentto the annulus of a heart valve and a post 444 connected to supportmember 442 and including an annular or loop-shaped end 446. As withprevious embodiments of the invention, one or more flexible tensilemembers or artificial chords may be affixed to end portion 446 andconnected at an opposite end to one or more valve leaflets (not shown).Post 444, and especially loop-shaped end portion 446, provides aresilient structure for bearing against the internal wall of the heartmuscle. At least end portion 446 can flex in a resilient fashion towardring-shaped support member 442 as the heart muscle contracts and moves.This reduces the likelihood of injury to the heart muscle and providesan artificial chord support that more naturally mimics the operation ofa papillary muscle.

FIG. 29 illustrates an alternative valve support device 440′, which maybe configured similarly to valve support device 440, except that post444 is connected to ring-shaped support member 442 by an adjustable andlockable connection 450. This allows adjustment in the direction orarrows 452, 454. After the appropriate adjustment is made, post 444 maybe locked in the desired position with a set screw 456 tightened againstring-shaped support member 442. A slot 450 a also allows post 444 to becompletely removed from support member 442.

FIG. 30 illustrates a valve support device 460 similar to device 440,but having a support member 462 which is not ring-shaped and having apost 464 with first and second loop-shaped end portions 466, 468. One ormore flexible tensile members 470, 472 may be retained on post 464 andloop-shaped end portions 466, 468 by suitable rings 474, 476 allowinglength adjustment of flexible tensile members 470, 472. Flexible tensilemembers 470, 472 may extend upwardly past support member 462 and may betied thereto after length adjustment is made.

FIG. 31 illustrates a valve support device 480 comprising separatesupport members 482, 484 affixed to opposite sides of a heart valveannulus 486. A post 488 connects support members 482, 484 togetherthereby affixing the position of these opposite portions of heart valveannulus 486 with respect to one another. This may be used to pull twovalve leaflets 490, 492 together. Also, device 480 may be used toremodel the shape of annulus 486.

FIG. 32 is a valve support device 500 constructed in a similar manner tosupport device 480, but allowing further adjustability. Specifically,first and second valve annulus support members 502, 504 are respectivelyconnected to opposite sides of a heart valve annulus 506. At least oneand preferably two telescopically adjustable posts 508, 510 connectsupport members 502, 504 together. In the configuration shown, one orboth posts 508, 510 may be adjusted in length depending on theparticular malformation or abnormality of leaflets 512, 514. Onceadjusted to the appropriate length by the surgeon, telescopic posts 508,510 may be fixed at the desired length by any suitable means.

FIG. 33 illustrates another alternative valve support device 520comprised of a ring-shaped support member 522 configured to be connectedwith a heart valve annulus 524 and a post 526 generally constructed witha J-shape as in certain previous embodiments. In this embodiment,however, post 526 connects directly with valve leaflets 528, 530 by wayone or more spiral coil connectors 532, 534 extending outwardly frompost 526. As the surgeon pushes these wires 532, 534 from post 526, theywill form the coiled shape shown in the figure and simultaneously bedirected through leaflets 528, 530 to connect these leaflets at acentral location.

FIG. 33A illustrates another valve support device 540 similar to device520 but utilizing separate valve support members 542, 544 in place of aring-shaped support member and further including a centralized poststructure 546 comprised of post members 546 a and 546 b. Again, thesurgeon will install this device by affixing support members 542, 544 tothe heart valve annulus 524 and then as coiled wire connectors 548, 550are pushed through post portion 546 b, they will simultaneously becoiled and directed through valve leaflets 552, 554 to connect centralportions thereof together.

While the present invention has been illustrated by a description ofpreferred embodiments and while these embodiments have been described insome detail, it is not the intention of the Applicants to restrict or inany way limit the scope of the appended claims to such detail.Additional advantages and modifications will readily appear to thoseskilled in the art. The various features and concepts of the inventionmay be used alone or in numerous combinations depending on the needs andpreferences of the user. This has been a description of the presentinvention, along with the preferred methods of practicing the presentinvention as currently known. However, the invention itself should onlybe defined by the appended claims, wherein I claim:

1. A method for implanting an annuloplasty device and repairing a mitralvalve, the mitral valve having a valve annulus, the valve annulus havingan annulus anterior portion and an annulus posterior portion, theannulus posterior portion and the annulus anterior portion defining amitral valve opening therebetween, the annulus posterior portion havinga generally arcuate shape, the mitral valve having an anterior valveleaflet attached to the annulus anterior portion and a posterior valveleaflet attached to the annulus posterior portion, the anterior andposterior leaflets having respective anterior and posterior freemargins, the anterior and posterior leaflets movable between a closedsystolic configuration in which the free margins are in an approximatedspatial relationship, and an open diastolic configuration in which thefree margins are spaced apart to allow blood flow through the mitralvalve opening generally along a valve-flow axis; the annuloplasty devicecomprising an anterior section and a posterior section coupled to theanterior section, the posterior and anterior sections divided along afirst axis, the annuloplasty device having a maximum width dimensionalong the first axis, the posterior section having a generallycurvilinear shape and including a permanent deformation such that theposterior section is non-planar with respect to the anterior sectionwhen viewed in a direction generally parallel to the first axis; andwherein the method comprises: i) attaching the anterior section of theannuloplasty device to the annulus anterior portion, and ii) attachingthe posterior section of the annuloplasty device to the annulusposterior portion such that the permanent deformation is retained afterattachment of the anterior and posterior sections to the annulus therebyfixing the annulus posterior portion into a non-planar configuration toimprove coaptation of the leaflet free margins in the systolicconfiguration.
 2. The method of claim 1, wherein the annuloplasty deviceposterior section is permanently formed into first and secondsubsections, the first subsection being asymmetric relative to thesecond section about a second axis bisecting the annuloplasty devicealong the first axis, the first and second axes being perpendicular toeach other, and the method further comprises: using the first,asymmetric subsection to assist with bringing the leaflet free marginstogether in the systolic configuration.
 3. The method of claim 1,wherein the permanent deformation includes a bend, and attaching theposterior section further comprises: orienting the bend to extend in thedirection of normal blood flow along the valve-flow axis.
 4. The methodof claim 1, wherein the posterior and anterior sections together form aclosed ring-shaped member and the method further comprises: fixing theclosed ring-shaped member along and in close proximity to the annulus.5. The method of claim 4, wherein the ring shaped member issubstantially “D” shaped when viewed in a direction parallel to thevalve-flow axis, and attaching the anterior and posterior sections ofthe annuloplasty device further comprises: attaching a substantiallystraight portion of the “D”-shape to the annulus anterior portion, andattaching a substantially arcuate portion of the “D”-shape to theannulus posterior portion.
 6. The method of claim 5, wherein theannuloplasty device posterior section is permanently formed into anasymmetric shape relative to a second axis bisecting the annuloplastydevice along the first axis, the first and second axes beingperpendicular to each other, and the method further comprises: using theasymmetric shape to assist with bringing the leaflet free marginstogether in the systolic configuration.
 7. A method for implanting anannuloplasty device and repairing a mitral valve, the mitral valvehaving a valve annulus, the valve annulus having an annulus anteriorportion and an annulus posterior portion, the annulus posterior portionand the annulus anterior portion defining a mitral valve openingtherebetween, the annulus posterior portion having a generally arcuateshape, the mitral valve having an anterior valve leaflet attached to theannulus anterior portion and a posterior valve leaflet attached to theannulus posterior portion, the anterior and posterior leaflets havingrespective anterior and posterior free margins, the anterior andposterior leaflets movable between a closed systolic configuration inwhich the free margins are in an approximated spatial relationship, andan open diastolic configuration in which the free margins are spacedapart to allow blood flow through the mitral valve opening generallyalong a valve-flow axis; the annuloplasty device comprising an anteriorsection and a posterior section coupled to the anterior section, theposterior and anterior sections divided along a first axis, theannuloplasty device having a maximum width dimension along the firstaxis, the posterior section having a generally curvilinear shape andincluding permanent deformations such that the posterior section isnon-planar with respect to the anterior section when viewed in adirection generally parallel to the first axis and such that a portionof the posterior section is deformed inwardly toward the anteriorsection; and wherein the method comprises: i) attaching the anteriorsection of the annuloplasty device to the annulus anterior portion, andii) attaching the posterior section of the annuloplasty device to theannulus posterior portion such that the permanent deformations areretained after attachment of the anterior and posterior sections to theannulus thereby fixing the annulus posterior portion into a non-planarconfiguration and moving the annulus posterior portion inwardly towardthe annulus anterior portion to improve coaptation of the leaflet freemargins in the systolic configuration.
 8. The method of claim 7, whereinthe annuloplasty device posterior section is permanently formed intofirst and second subsections, the first subsection being asymmetricrelative to the second section about a second axis bisecting theannuloplasty device along the first axis, the first and second axesbeing perpendicular to each other, and the method further comprises:using the first, asymmetric subsection to assist with bringing theleaflet free margins together in the systolic configuration.
 9. Themethod of claim 7, wherein the permanent deformation includes a bend,and attaching the posterior section further comprises: orienting thebend to extend in the direction of normal blood flow along thevalve-flow axis.
 10. The method of claim 7, wherein the posterior andanterior sections together form a closed ring-shaped member and themethod further comprises: fixing the closed ring-shaped member along andin close proximity to the annulus.
 11. The method of claim 10, whereinthe ring shaped member is substantially “D” shaped when viewed in adirection parallel to the valve-flow axis, and attaching the anteriorand posterior sections of the annuloplasty device further comprises:attaching a substantially straight portion of the “D”-shape to theannulus anterior portion, and attaching a substantially arcuate portionof the “D”-shape to the annulus posterior portion.
 12. The method ofclaim 11, wherein the annuloplasty device posterior section ispermanently formed into an asymmetric shape relative to a second axisbisecting the annuloplasty device along the first axis, the first andsecond axes being perpendicular to each other, and the method furthercomprises: using the asymmetric shape to assist with bringing theleaflet free margins together in the systolic configuration.